J. Eric Gordon

Periacetabular osteotomy for the treatment of severe acetabular dysplasia

BACKGROUND The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients. METHODS Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively. RESULTS Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees ) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees ) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees ) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures. CONCLUSIONS The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Complications of titanium elastic nails for pediatric femoral shaft fractures.

Limited data exist about complications of titanium elastic nails (TNs) for femur fracture management in pediatric patients. Thirty-nine patients with 43 femoral shaft fractures were identified whose average age was 6.0 years. There were 21 complications (1 intraoperative, 20 postoperative) in 43 femur fractures (49%). There were two major postoperative complications: one septic arthritis after nail removal and one hypertrophic nonunion. Minor postoperative complications were pain at the nails in 13 extremities, nail erosion through the skin in 4, and one delayed union. There was an association between the prominence of TNs and nail pain or skin erosion. Fracture angulation and outcome were associated with the patients weight and size of the nails implanted. Technical pitfalls exist with this implant and can be minimized by leaving less than 2.5 cm of nail out of the femur and by using the largest nail sizes possible.

Fracture stability after pinning of displaced supracondylar distal humerus fractures in children.

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeons discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.

Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms.

BACKGROUND Differentiation between septic arthritis and transient synovitis of the hip in children can be difficult. Kocher et al. recently developed a clinical prediction algorithm for septic arthritis based on four clinical variables: history of fever, non-weight-bearing, an erythrocyte sedimentation rate of >or=40 mm/hr, and a serum white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L). The purpose of this study was to apply this clinical algorithm retrospectively to determine its predictive value in our patient population. METHODS A retrospective review was performed to identify all children who had undergone a hip arthrocentesis for the evaluation of an irritable hip at our institution between 1992 and 2000. One hundred and sixty-three patients with 165 involved hips satisfied the criteria for inclusion in the study and were classified as having true septic arthritis (twenty hips), presumed septic arthritis (twenty-seven hips), or transient synovitis (118 hips). RESULTS Patients with septic arthritis (true and presumed; forty-seven hips) differed significantly (p < 0.05) from patients with transient synovitis (118 hips) with regard to the erythrocyte sedimentation rate, differential of serum white blood-cell count, total white blood-cell count and differential in the synovial fluid, gender, previous health-care visits, and history of fever. If the four independent multivariate predictors of septic arthritis proposed by Kocher et al. were present, the predicted probability of the patient having septic arthritis was 59% in our study, in contrast to the 99.6% predicted probability in the patient population described by Kocher et al. Statistical analyses demonstrated that the best model to describe our patient population was based on three variables: a history of fever, a serum total white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L), and a previous health-care visit. When all three variables were present, the predicted probability of the patient having septic arthritis was 71%. CONCLUSIONS Although the use of a clinical prediction algorithm to differentiate between septic arthritis and transient synovitis may have improved the utility of existing technology and medical care to facilitate the diagnosis at the institution at which the algorithm originated, application of the algorithm proposed by Kocher et al. or of our three-variable model does not appear to be valid at other institutions.

Surgical correction of the snapping iliopsoas tendon in adolescents

Background: There have been very few reports regarding symptomatic snapping of the iliopsoas tendon, and none of those reports have dealt exclusively with an adolescent population. We report our experience with the surgical treatment of this entity in a group of patients who had an average age of fifteen years.Methods: Nine adolescent patients (eleven hips) underwent fractional lengthening of the iliopsoas tendon at the musculotendinous junction because of persistent painful snapping of the hip. A modified iliofemoral approach to the iliopsoas tendon was used. The diagnosis in all cases was made on the basis of the history and a physical examination. Plain radiographs were made for all patients to rule out an osseous intra-articular loose body. Follow-up consisted of personal interviews and physical examinations performed at least two years postoperatively.Results: Preoperatively, all patients had audible snapping with pain localized to the anterior part of the groin. The average duration of symptoms was 2.3 years. Prior to the onset of symptoms, all but one of the patients had been involved in competitive athletic activities. Postoperatively, all patients were able to return to the preoperative level of activity without subjective weakness. The average duration of postoperative follow-up was four years. Hip-flexion strength was noted to be nearly equal to that on the contralateral side. All patients reported that they would have the operation again under similar circumstances. One patient had recurrent snapping but stated that it was less frequent and less painful than the preoperative snapping. Two patients had transient sensory loss in the anterolateral aspect of the thigh.Conclusions: We conclude that fractional lengthening of the iliopsoas tendon at the musculotendinous junction is an effective and safe approach for adolescent patients with persistent symptomatic snapping of the iliopsoas tendon that is unresponsive to conservative measures.

Complications after titanium elastic nailing of pediatric tibial fractures

A retrospective review of 60 diaphyseal tibia fractures (31closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal. The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.

Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity

Ponseti demonstrated correction of most clubfeet in infants using proper manipulative techniques followed by application of well-molded long-leg plaster casts and a percutaneous tendoachilles tenotomy to correct residual equinus contracture. Medical complications occurring as a result of this technique have not to our knowledge been reported. The authors retrospectively reviewed 134 consecutive infants with 219 idiopathic clubfeet treated with the Ponseti method. A percutaneous tendoachilles tenotomy was performed on 200 clubfeet (91%) at a mean age of 16 weeks (range, 6–77 weeks) when less than 10° of ankle dorsiflexion was present after casting. A total of 4 patients had serious bleeding complications following the percutaneous tendoachillis tenotomy—3 due to presumed injury to the peroneal artery and 1 due to injury to the lesser saphenous vein. The authors detail the technique of performing a percutaneous tendoachilles tenotomy and offer guidelines that may help others avoid this same complication.

Antegrade Intramedullary Nailing of Pediatric Femoral Fractures Using an Interlocking Pediatric Femoral Nail and a Lateral Trochanteric Entry Point

Background: The treatment of femoral shaft fractures in older children and adolescents using rigid intramedullary (IM) nail fixation offers the advantages of decreased soft tissue stripping, low incidence of malalignment, leg length discrepancy, early ambulation, and decreased hospital stay. Recent reports have described the development of osteonecrosis of the femoral head in children after IM nailing through the piriformis fossa and the tip of the greater trochanter. Others have noted secondary proximal femoral valgus and femoral neck narrowing after antegrade IM nailing. Using the lateral aspect of the greater \trochanter as the starting point avoids the tenuous blood supply of the proximal femur and did not seem to produce avascular necrosis or proximal femoral deformity in early reports. Methods: A retrospective clinical and radiographic review of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. Twenty-four fractures were observed until skeletal maturity. Final standing anteroposterior radiographs of both lower extremities were used to assess for evidence of osteonecrosis, limb length discrepancy, fracture alignment, and indices around the hips. Results: All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions, or malunions were observed. Two patients developed infections postoperatively (2.5%). No patient had evidence of osteonecrosis of the femoral head. There was no significant difference in neck-shaft angle, articulotrochanteric distance, or femoral diameter when compared with the nonsurgical, normal side in these patients. Conclusions: Intramedullary nail fixation through the lateral aspect of the greater trochanter in children and adolescents is effective. It does not produce clinically important femoral neck valgus or narrowing. We did not observe osteonecrosis of the femoral head. Level of Evidence: Level IV, case series.

Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique.

BACKGROUND The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients. METHODS Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively. RESULTS Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures. CONCLUSIONS The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Use of an intramedullary rod for treatment of congenital pseudarthrosis of the tibia: A long-term follow-up study

BACKGROUND The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia. METHODS Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years). RESULTS Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity. CONCLUSIONS This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.